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Provider Update Newsletter

April 2003, Volume 126
 

All Providers

HIPAA Happenings
Did You Know?

Pharmacy Providers

HIPAA NCPDP POS 5.1 and Batch 1.1 Pharmacy Implementation
The New Pharmacy Prior Authorization Process

Assisted Living Providers Providers

Procedure Codes for Assisted Living Waiver Client's

HIPAA Happenings

Frequently Asked Questions
Please visit the DHS HIPAA Page (make the bolded section the link to the hipaa page) for a list of frequently asked HIPAA questions and their answers. These Q & A’s have been compiled from numerous requests that DHS has received via email. Please check this list prior to submitting questions or surveys to DHS. You will get your answers more quickly and might find some important questions you hadn’t thought of asking.

Here are a few of the Frequently Asked Questions and their answers:

What HIPAA transactions will we be processing?
837 Healthcare Claim Professional, Dental, and Institutional
270 Healthcare Eligibility Benefit Inquiry
276 Healthcare Claims Status Request
NCPDP 5.1 Batch Pharmacy Claim
820 & 834 Managed Care Payment/Enrollment

What HIPAA transactions will EDS be sending?
835 Healthcare Payment/Advice
271 Healthcare Eligibility Benefit Responses
277 Healthcare Claim Status Responses
997 Functional Acknowledgement
NCPDP 1.1 Batch Pharmacy Response

When will you begin accepting HIPAA compliant transactions?
October 2003

When will testing commence?
Tentative Dates

• Communications Testing 4/03 - All Providers

• Syntax Testing 5/03 - All Providers

• End to Date Testing 7/03 - Specific Providers/Billing Groups

Please check the DHS HIPAA web site regularly for HIPAA Updates

Did You Know?

You can access all the provider manuals on the DHS Website.
Save this in your favorites and your can refer to this at anytime

HIPAA NCPDP POS 5.1 and Batch 1.1 Pharmacy Implementation

As a result of the responses to the Pharmacy survey on NCPDP POS 5.1 and batch 1.1 
standards readiness, DHS and EDS have delayed rollout of the new standards until 
July 1, 2003. This date will allow Pharmacy providers to implement the new HIPAA 
related standards.

Specifics regarding testing, certification and overall implementation will be provided to you 
and your vendors and made available on the DHS Web site on the HIPAA page. Please 
contact our support staff or vendors to confirm that they started the testing and certification 
process with WebMD and EDS. If you have any questions, please feel free to contact the 
EDS Pharmacy Coordinator, Ingelcia Jiran at (401) 784-3818 or by email.

 

The New Pharmacy Prior Authorization Process

On November 25, 2002, DHS and EDS began processing pharmacy prior authorization (PA) 
requests through the new, innovative Smart PA process. The Smart PA process begins when a 
pharmacy claim is submitted via POS. The POS pharmacy claim request is analyzed automatically, 
first by the MMIS system, and then by the Heritage Information Systems Smart PA tool. Based 
on the set of clinical rules established by Department of Human Services (DHS), a systematic 
determination is arrived at which is translated into a claims approval message being returned to the 
pharmacy POS, and the generation of a prior authorization. If the criteria is not met, then a POS 
message will be returned to the pharmacy POS advising of the claim denial.

This process allows prior authorizations to be based on patient history, minimizing the amount of 
manual work involved in obtaining prior authorization for certain classes of drugs. Additionally, if 
a claim and the corresponding request for a prior authorization is denied because a clarification of 
need or medical necessity is required, the provider can access a clinically staffed call center which 
will guide the provider in supplying the additional documentation or information.

Specifics regarding the new Smart PA process have been previously provided and continue to be 
available on the DHS Website or by contacting the EDS help desk at (401) 784-8100.

Procedures Codes for Assisted Living Waiver Client's

Please note as of March 1, 2003 your billing will now go to EDS.

The following procedure codes are used for Assisted Living Waiver Client’s

SS630 – Adult Residential Care/Community Support – Assisted Living Per Day
W7501 – Case Management Every 15 Minutes – Assisted Living
S4610 – Minor Assistive Devices – Assisted Living Waiver

Helpful hints for claims processing

• Do not deduct the client’s liability from the total billed amount. This will be done when the claim is processed for pricing.

• Day of discharge is not billed.

• Please contact us at (401) 784-8100 if you have any questions regarding billing for Assisted Living claims or if you require the free PES software to bill us electronically.